Dr. Endang Melati Maas, SpAn.

KIC
Department of Anesthesiology & Reanimation
Faculty of Medicine, Unsri
palembang
1

 Euthanasia derives from the Greek Euthanos

Eu means good, with no pain and thanatos
means death
Euthanasia means good death with no pain
The development of euthanasia has never been
away from the development of death concept

In Indonesia, according to Indonesian Medical

Ethics Code, the terminology of euthanasia
used today means:
1. The moving of the body to the other world
safely and peacefully, with no pain, for those
with his faith would say Allah on lips
2. When the life ends. The pain of the sick may
be lighted by administering the tranquillizer
3. Put an end to the sick mans life and suffering
intentionally upon his and his familys will
3

Euthanasia differs from:

1. Active euthanasia
2. Passive euthanasia
3. Auto euthanasia

 Active euthanasia is an intentional action

conducted by the doctor or other medical
professionals to shorten or put an end on
patients life
Passive euthanasia is a condition on which
doctors or other medical professionals give
no medical life supports to prolong patients
life intentionally
5

 Auto euthanasia is a condition on which

patients by his concerns strongly reject
receiving the medical treatment and he
knows it may shorten or end his life, by
this rejection he makes his hand- written
statement
Fundamentally Auto euthanasia is a
passive euthanasia upon his demand

The issue of euthanasia raises pro and contra

Those who disagree euthanasia argue that
euthanasia is a silence killing, therefore it is against
the Gods will
Those who agree euthanasia affirm that this action is
upon patients will and conducted to lighten patients
pain.
There is a mercy for those severely sicked and no
medical expectation to live, together with a respect
to mankind by a free choice as human rights.
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Definitions of death
In the unconscious state patient certainly
would not receive the agreement from the
patient and at least the doctor asks his
family, so there raise a question
When a patient considered dead?
When all medical support stopped?

The terminology of death

Clinical death
Cerebral death, cortical death
Biological death
Social death

 Clinical death is a condition on which

respiratory arrest/no spontaneous
breathing and cardiac arrest by
terminating all cerebral activities
irreversibly
Cerebral death is an irreversible damage
of cerebrum, particularly in neocortex and
othe supratentorium structures, but
medulla works well
10

 Brain death is a cerebral death

accompanied by thorough necrotic brain
including cerebellum, mid brain and
brainstem
Biological death (pamorganic death) is an
unpreventable death after the clinical
death if no cardio-pulmonary-brain
resuscitation performed or the
resuscitation fails
11

 Biological death is an autolytic process in

all tissues starting from the neuron cells
turning into necrotic without any circulation
within an hour, accompanied by heart,
kidneys, lungs and liver necrotized within
2 hours after having no circulation and
ended by necrotizing skin within hours or
days

12

 Social death is a persistent vegetative

state suggesting the irreversibly severe
brain damage in an unconscious and
irresponsive patient but has an active
EEG, few reflexes and ability to breathe
spontaneously.

13

The criteria of brain death applied in

University of Pittsburgh since 1968
1. No cerebral and brainstem activity
confirmed by 2 times clinical examination
within 2 hours, without any depressant
drugs on CNS, relaxant and hypothermic
2. EEG suggests isoelectrics with the least of
30 minutes auditory stimuli

14

 KUHP article 344: those who terminate

others life upon his will, by which he
mention it clearly and seriously will be
condemned within the least of 12 years in
jail
KUHP article 345: those who intentionally
persuade others to commit suicide,
assisting him to do it, or encourage him to
commit suicide will be condemned within
the least of 4 years in jail
15

 KUHP article 338: those who intentionally

terminate others life, due to common homicide
will be within the least of 15 years in jail
KUHP article 340: those who intentionally and
plan to terminate others life will be condemned
due to the planned murder (moord) with capital
punishment or jailed within the least of 20 years
or through his life
KUHP article 359: those by their own cause
people died will be condemned within the least
of 5 years in jail or 1 year in the detention home
16

 Concerning the articles of KUHP in either

active or passive euthanasia prohibited in
Indonesia, however if it regards the
terminology of torturing in KUHP article
351(torturing), does the administration of
ineffective treatment for the sake of
patients recovery mean a torture to the
patient?

17

 That current issues of death determination

together with the termination/ delay on life
support remain a major issue encountered by
the doctors both in or outside hospital
For instance: how to assert the classic death,
brainstem death and the follow up remain
obscure to us
In addition, how we encounter this no hope
to this recovery patient waiting for his dead
end remain obscure to us.

18

 Year 1986: holding the workshop about

the termination of long period
resuscitation. The participants are the
representatives of clinical association
by means of IDI, law professionals,
social and clergies.
The event organizers are IDI and PKGDI

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 The outcome of this workshop is to

legalize the termination of
extraordinary life support on ICU
patients waiting for his dead end.
Formerly this was called by passive
euthanasia but today the used term is
with-drawing/with-holding life supports

20

According to IDI recommendation 1988

and 1990, a person so called dead if:
a. Spontaneous respiratory and
cardiovascular function have stopped
irreversibly (classic death) or
b. Proven to be brainstem death

21

 Clinical death is a condition on which spontaneous

respiratory and cardiovascular function have stopped
and known after being performed an emergence
resuscitation
Clinical death is respiratory arrest (no spontaneous
respiration) together with total cardiovascular arrest
with all brain activities stopped, but reversible
Cardio death is a continuous asystolic ventricular
(flat graphics on ECG) during the least of 30 minutes
after being performed resuscitation and optimal
treatment.

22

 MBO is brainstem death

The termination of life supports (so called
passive euthanasia is to terminate half or full
life support therapies given to the patients
The delay of life supports (so called passive
euthanasia) is not to give life supports for a
new abnormality aroused, while proceeding
the given therapy

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Signs of clinically dead person or

cardio/respiratory arrest, are:
1. Unconscious
2. Cardiovascular-circulation cessation, on which
carotid artery has no pulsation
3. Spontaneous respiratory arrest (on which no
breath after being performed the examination
by cotton/fibers/glass) or gasping
4. Death like appearance
5. Pale skin color to gray
6. Pupils dilatation
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If the livor mortis, and or rigor

mortis found in the dead body
then can be said irreversibly
dead.

25

The effort of resuscitation performed in

clinical death is when the pulse of
bigger artery (circulation) and
respiratory stop but hesitated if both
cardiovascular and respiratory function
fail irreversibly.
For examples:

26

 Minor cardiac infarct, causing electrical

death
Adams-stroke attack
Acute hypoxia
Drugs Intoxication and over dosage
Electrical shock
Drowned and other accidents that give
chance to live

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Resuscitation not performed when:

Patient with the criteria of do not resuscitate or all
treatments excluding CPR:
for patients with functional brain or hope for brain
recovery, which undergo the cardiopulmonary failure or
other multiple organs in terminal stage of the incurable
disease, e.g. advance carcinomatosis.
All possible treatment comfort the patients. Prolonging
life will not be performed after cardiac arrest.
If it happens CPR will not be performed and patient
neglected dead
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In the emergency setting, resuscitation may be

ended when there has one of these followings:
1. If reappears an effective spontaneous circulation
and ventilation
2. The effort of resuscitation taken over by other
more competent personnel and responsible to
proceed the resuscitation if no doctors)
3. A doctor takes over the responsibility if there is no
doctors previously)
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4. The assistants are so weak that they are

unable to proceed the resuscitation
5. Patient confirmed dead
6. Previously known that after the resuscitation
started, patient remains in the terminal stage of
an incurable disease: or nearly confirmed that
the patient will not gain back their cerebral
function, namely 0,5 -1 hour, proven to have
no pulse in normothermic without CPR.
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Long term resuscitation ended when

meeting one of these followings:
1. Brainstem death
2. The terminal stage of an incurable
disease e.g. social death

31

 The decision of brainstem death is a medical

decision, so that the authorities is given to the
medical professionals.
The medical professionals consist of 3
competent doctors of which one of them is
anesthesiologist/intensivist, and the other 2
doctors).
The decision is made in the examination report
and the decision making
32

 That before performing the examination

procedure of having no brainstem reflex, doctors
are obliged to explain the patients condition,
extent of brainstem death definition and the
follow up to the patients condition if any)

33

Signs of brainstem function loss are:

Comatose
No abnormality of body posture
(decorticated or decerebrated)
No epileptic jerk
No brainstem reflex
No spontaneous breathing

34

Requirements and procedures of

brainstem death procedures are:
1.

Ensuring that there is some certain condition, such as

comatose and apnea together with the incurable brain
structure damage owing to disorders toward
brainstem death

2.

Eliminating the irreversible cause of comatose and

respiratory arrest (drugs, intoxicated, electrolytes
disorder, metabolic and endocrine)

3.

Ensuring the non-reflexive permanent brainstem and

respiratory arrest
35

Brainstem reflexes are:

1.
2.
3.
4.

No light response
No cornea reflex
No vestibulo-occular reflex
No motor response in distributing the cranial
nerves to the adequate stimulation in somatic
area
5. No vomiting reflex gag reflex) or coughing
reflex to the stimulation of the inserted suction
catheter into trachea

36

Difficulties in diagnosing the brainstem death

Examination outcome

Possible causes

Negative Occulo vestibular reflex

Ototoxic drugs
Vestibular supressor drugs
Previous disease

No breathing

Respiratory arrest post ventilation

Muscle relaxant drugs

No motoric activities

Muscle relaxant drugs

Locked in state
Sedatives drugs

EEG: iso electric

Sedatives drugs
Anoxia
Hypothermic
Encephalitis
trauma

Fixated pupil

Anti cholinergic drugs

Muscle relaxant drugs
Previous disease

37

 The test needs to be repeated to prevent

the problems of observation and signals
change.
The time interval ranges in 25 60
minutes to the related hospital in regard of
transplantation; other hospital is 24 hours
maximally.
If the retest remains negative, the patient
is asserted dead though the heart beats.
38

 Brainstem death determination in particular for the

interest of transplantation, the test is performed by
3 competent doctors of which one of them is
anesthesiologist/intensivist, and the other 2
doctors).

The 3 doctors ought to have no relation to

transplantation.
The patient is dead when brainstem is dead, not
when the dead body was ejected from the ventilator
and the heart stops beating, then immediately
consult it to the transplantation team
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 Notice that normally the cause of death is

the primary disease of the patient, not
from the withdrawing or rejection of life
supports.

40

 The withdrawal means to stop the given

therapies.
The supports may be more comfortable by
withdrawing the therapy/life support than
rejecting new therapy owing to its ineffectively
proven to the patient.
They ensure that withdrawing may cause the
primary disease inflicting the patient.

41

 When the machines turned off, attempted

to return the patients spontaneous
breathing.
If fails, the ventilator therapy may no
longer be installed.
If unpredictably, patient breathes
adequately spontaneous, then the attempt
to secure patient continued

42

Criteria of the termination/delay of

life supports
1. Irreversible abnormality/disease.
2. Poor prognosis in the aspect of medical
and quality of life.

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Extraordinary treatments to life supports

1. Treated in ICU
2. CPR
3. Disrythmia control
4. Tracheal intubations
5. Mechanical ventilation
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6. Strong vasoactive drugs

7. Total parenteral nutrition
8. Antibiotics
9. Enteral tube feeding
10. IV line fluid (DWS,NS,RL)

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Dank fur ihre

aufmerkamseit

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